Provider Demographics
NPI:1942554423
Name:GOLDEN, MELISA JO
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:JO
Last Name:GOLDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 E 24TH STREET
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460
Mailing Address - Country:US
Mailing Address - Phone:580-371-9933
Mailing Address - Fax:580-371-9944
Practice Address - Street 1:504 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3214
Practice Address - Country:US
Practice Address - Phone:580-371-9933
Practice Address - Fax:580-371-9944
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200443090AMedicaid